Opening Case Study
Angel had recently been diagnosed with a tumor in his neck which would require surgical removal. Dr. Rau had been gentle but honest when Angel had asked him how his surgery might affect him. At age 35, the news was not easy for Angel to hear.
“I will do everything I can to change your appearance as little as possible,” Dr. Rau had said. “But with the size of your tumor, I have to be honest with you. You will have a scar, and some disfiguration on that side of your face. You may also experience minimal nerve damage. This will affect your speech, at least for a few months.”
Dr. Rau had gone on to explain what he meant when he said that Angel’s face would be disfigured. But after hearing that word, followed by learning that his speech would be affected, Angel had stopped listening. He lowered his head and looked downward, and held his face in his hands.
Keep in Mind: How would you be feeling if you received Angel’s news? Looking one’s best, and speaking clearly, are important to how we present ourselves to others. If you learned that you would experience changes in the way that you look or speak, what would be most concerned about?
After meeting with Dr. Rau, Angel went into the lab to see Ava, Dr. Rau’s medical assistant, and have a blood sample taken. Ava knew that Dr. Rau would be talking with Angel about his surgery, and she noticed that Angel was quiet, and was not smiling and asking her about her children like he had on previous visits. He seemed to avoid making eye contact with her.
“Angel, it looks like you are having a rough time today.”
“You’re right,” he answered. “I am. And I guess you know why.”
Angel liked Ava and he didn’t want to say anything that might seem like he was angry at her, which he wasn’t. But Angel felt like getting mad at life. He had always been proud of his appearance, and was often told that he was a good-looking guy. His wife certainly told him he was. And as a teacher, how would he be effective in his classroom if he had trouble talking? And what about hanging out with his buddies? Would they even want to be around him?
Angel had accepted his diagnosis, and he knew that the surgery to get rid of the tumor, even though it was relatively small, would still be complicated.
But he hadn’t expected news like he received today. He felt even worse than the day he received his diagnosis.
Keep in Mind: Newly-diagnosed patients who are facing the prospect of changes that may impact their self-image experience realistic fears and doubts about what their future might be like. Would you identify with the patient’s feelings of helplessness in a way that might help you to understand his/her feelings, or would your feelings of helplessness make the conversation more difficult for you?
Ava positioned a chair directly across from Angel, and leaned forward toward him.
“Dr. Rau went over your case with me,” Ava said. “So I know your surgery is most likely going to have some long-term effects. I know this hard for you to have to deal with right now, so soon after learning about your condition.”
“It is very hard,” Angel answered. “I am a person who takes a lot of pride in how he presents himself to others. I work hard to feel good about myself inside, to feel like a strong person, and to have others think of me the same way. This is who I have always been and who I intended to be in the future.”
Angel stopped and looked away. He was afraid that if he kept talking, he would start crying. The last thing he wanted to do was to show any more weakness; he felt that he looked weak enough already.
“We have had a lot of patients go through what you’re experiencing,” Ava said. “I could talk with you about how they have coped.”
Ava wanted to at least open the door for Angel to talk with her more. She wasn’t sure if he was talking with anyone else about how his surgery would impact his self-image. Also, she wanted to help make sure that he was as emotionally prepared as possible for his surgery because he had a long recovery period ahead of him, and it would be important for Angel to be compliant and optimistic during his recovery period.
Angel didn’t respond to Ava’s offer to talk more. She knew he needed some time on his own to process what Dr. Rau had told him.
Keep in Mind: Ava knows that she has to approach the discussion of Angel’s self-image carefully. She doesn’t want to offer false promises, nor does she want to discourage him. If a patient in this situation wanted to talk to you about it, what would your goal be for this conversation? Where would this conversation take place? What would you want your body language to look like?
Introduction
“I’m not ever going to be the same.”
Newly-diagnosed patients live with fear and uncertainty regarding how their diagnosis will affect their daily lives. One of their concerns is that the they won’t feel, function, or look like themselves anymore, that the condition or its treatment will have make them unrecognizable in some way to themselves as well as to others. They may be experiencing cognitive symptoms, such as forgetting or lack of concentration, which affects their ability to interact with others or to do their jobs effectively. The emotional impact of the diagnosis, as well as the challenges of going through treatment, can result in mood changes, which can in turn impact how they present themselves to others.
Any of these changes can have a negative impact on self-image. Newly-diagnosed patients may feel that they have changed in ways that makes them less than others, needy, unattractive, uninteresting, or ineffective. They may feel that the condition or its treatment has left them so damaged that some or all of the aspects of themselves that they and others value the most are going to disappear. And if so, what remains?
Patients with low self-image present a number of challenges for their healthcare team. When their self-image suffers, newly-diagnosed patients are less likely to have the optimism and determination to cope effectively with their condition and its treatment. They are likely to be less complaint with their treatment regimen and lifestyle management. They may not communicate symptoms and other changes that their healthcare team needs to know about. Furthermore, their negative outlook on the future can affect outcomes.
Healthcare professionals can help patients experiencing a low self-image by recognizing the signs of a low self-image and encouraging them in ways that include focusing on strengths and getting support.
SIDEBAR: SIGNS OF LOW SELF-IMAGE
Here are some signs that a patient may be experiencing a low-self image:
- Talking mainly about the past
- Apologizing for their feelings
- Having difficulty discussing the future
- Anxious, or angry, or depressed
- Low energy
- Speaking bitterly about their future
- Avoiding eye contact
- Hesitant to express an opinion
How a Medical Diagnosis Affects Self-Image
A person’s self-image is basically the mental picture they have of him/herself, and includes the way they look (or think they look), how successful they are, their abilities, and many other qualities. Some aspects of self-image, such as appearance, are observable by others, though their opinions of appearance might be different from the opinions of the person being observed. Other aspects of self-image are more personal, such as one’s perception of whether he/she is smart or successful. One’s self image may be similar in some ways to the way in which he/she is viewed by others, but will also most likely be different in other ways. For example, an individual may consider him/herself as being a great singer while others might have a very different opinion.
Self-image develops over time. Children learn how they are viewed by others – the attributes that others respond to most positively, such as having an outgoing personality, or being good-looking, or being a good piano player or athlete. Negative reactions by others also contribute to an individual’s self-image, such as being called inept in some way, or not feeling accepted by friends or family. During adolescence and on into adulthood, an individual’s self-image continues to develop, based on experiences at home and in the workplace: forming relationships, developing skills, and taking on increased responsibilities.
The experience of being diagnosed with a medical condition can have a major impact on self-image
Figure 9-__
An illustration of an individual comprised of the sub-heads below: physical appearance, abilities and talents, relationships, personality, self-esteem. Showing the individual questioning these aspects of him/herself.
Keep in Mind: It is human nature to make quick, and often unfair, judgments of others based on their physical appearance, based on factors such as attractiveness, weight, age, and other factors. Imagine what a newly-diagnosed patient may be feeling when learning that their appearance will be affected by their condition, temporarily or permanently. Much of this concern is based on fears of judgment from others.
Physical Appearance
Fairly or unfairly, people judge each other based on appearance. By looking at another person, decisions are made regarding how friendly that person might be, whether they might be a potential romantic partner, or how trustworthy they might be. Being told that one is attractive, and feeling like an attractive person, contributes to a positive self-image while feeling unattractive has a negative effect on self-image.
Medical conditions can affect appearance as can medical treatments, and changes in appearance can have a major impact on self-image. When newly-diagnosed patients experience changes in physical appearance, they experience these changes as the loss of an important aspect of their identity. They wonder: If I look different, am I still really me? They fear that their condition is now obvious to others and that they will be singled out in some way, that others will make comments about them, and that they will be treated differently. They may also fear that others will withdraw from them or avoid them, or that they will be an embarrassment to their families. Newly-diagnosed patients often experience anticipatory anxiety – that is, feeling afraid of something in advance of it actually occurring – in regard to their physical appearance. Often, this anxiety is not based on real information, or is based on the worst possible outcome.
The self-image of individuals who are experiencing a change in appearance, no matter how minor, can change dramatically, if they begin to see themselves as unattractive, damaged, or even ugly.
Abilities and Talents
A sense of being competent is an important aspect of self-image. This includes having abilities and talents that others recognize and reward. Examples might include being able to play a musical instrument, and performing at church or community events; having a high demand skill that leads to job security and a good salary; or being a good problem solver and relied upon by others for that skill. In American society, individuals often define themselves through what they do for a living, and through their abilities and accomplishments.
Newly-diagnosed patients may, at least temporarily, lose certain abilities. Work routines and previously enjoyed activities may need to be modified, or even discontinued, as part of lifestyle management. Certain activities, as well as work, may need to be curtailed or discontinued during treatments like chemotherapy. Opportunities to enjoy talents in areas like sports or art may become limited. Because what an individual does is so much a part of his/her identity, newly-diagnosed patients may feel that they have lost much of who they are. This in turn can have an impact on how they value themselves – their sense of self-worth – and lead to feeling inept and useless.
Relationships
Developing relationships contributes to one’s self-image. Human beings need to feel that they are part of a social network – family, friends, neighbors, co-workers. They need to feel wanted and needed by others, to have their thoughts and opinions valued, to care for others and to be cared for. Individuals define themselves in part by the people they surround themselves with, interests and activities they enjoy, the values they share, the ways in which they depend on each other.
Newly-diagnosed patients may feel a change in their personal relationships. Their condition may create new dependencies if they rely on family or friends to provide some form of support which may, in turn, changes the overall balance of the relationship. The roles that family members play may change. For example, a mother may need to be cared for when, formerly, she was the one who did all of the caring. Changes in relationships cause discomfort and, sometimes, even tension, if patients resent having to be more dependent and their family or friends either become controlling in their desire to take care of the patient or if they also resent the changes that the medical condition has brought about. Newly-diagnosed patients mostly experience as much, or more, anticipatory anxiety regarding potential changes in personal relationships than they experience in reality. In other words, they fear that their condition will change the way family and friends will relate to them.
As relationships change, or if this change is feared, the self-image of newly-diagnosed patients may suffer as a result because of concerns about being burden to others, or somehow not ‘measuring up’ to what their friends and family need, and therefore not a fully-functioning member of their social group.
Personality
Individuals have their own unique personalities – serious, funny, upbeat, stubborn, warm, assertive, shy… while most have some combination of these, and other qualities. Each individual is unique in terms of the presence or absence of these qualities, how these qualities are expressed, and under what circumstances. The result is personality, which is what makes human beings interesting to each other. Personality is also an important aspect of self-image – individuals are appreciated because of their personality characteristics. Basically, individuals have established patterns in terms of the way that they interact with people around them, playing roles like ‘listener,’ ‘advisor,’ ‘joker,’ and ‘leader.’ When these patterns are interrupted, relationships change. If a newly-diagnosed patient experiences a change in the way he/she interacts with others, e.g. when physically unable to be a joker or a leader, it is natural to fear that relationships will be lost.
Newly-diagnosed may experience various changes to their personalities, directly or indirectly related to their condition. The side effects of medication may include drowsiness or depression, among others. The condition itself may affect energy level or ability to concentrate which, in turn, can affect how patients relate to those around them. Emotions about the diagnosis and the early treatment experiences, like sadness or anger, will arise, as well as the sense of helplessness, and fear. Changes in how patients feel emotionally can, in turn, affect personality. Newly-diagnosed patients may not understand what is causing these changes, which can, in turn, result in confusion and fear. Changes in personality can also cause others to behave differently toward the patient, which can cause further confusion and fear related to changes in, or loss of, relationships.
Personality changes can impact self-image if valued personality characteristics that are valued by others seem to have disappeared, even temporarily. The newly-diagnosed patient may feel unrecognizable to him/herself as well as to others.
Keep in Mind: What role do you play in your relationships with the people you care about. Most likely, if circumstances prevented you from playing this role, at least temporarily, how would your relationships change?
Self-Esteem
The term self-esteem is often used interchangeably with self-image and they are, indeed, similar. Self-esteem is how individual’s value their own self-worth, and includes how feeling capable, having self-pride and self-respect, and being able to project a confidence and pride to others. Having a positive self-image is an important ingredient of self-esteem.
Psychologists usually discuss self-esteem as constant, meaning that self-esteem is a human trait that is relatively unchangeable (REFERENCE). However, life events can cause a change in self-esteem, at least temporarily, and a medical diagnosis is certainly one of them. Individuals who receive a medical diagnosis can feel that they are of no longer of value, or that they are incompetent or useless to others, or they may fear that they will become this way over time. Patients who feel responsible in some way for their diagnosis, e.g. due to living an unhealthy life, may criticize themselves, which further contributes to low self-esteem.
Feeling Special, Feeling Normal
Human beings place a high value on their own specialness. Everyone likes to feel that there is something interesting or unique that sets them apart from others, whether it is their attitude toward life, skills, personality characteristics. This sense of being special in some way adds to our self-image, and contributes to self-esteem and wellbeing. Yet at the same time, humans place a high value on normalcy. Most people don’t want to be too special. They want to have a day-to-day routine, and be able to participate in daily life without requiring additional assistance or consideration by others. In this regard, people want to be able to ‘blend in’ with others.
A medical diagnosis can threaten the balance between feeling special and feeling normal, for previously discussed reasons such as looking different, eating different foods, acting differently in some way, or not being able to participate fully in life. This results in fear and confusion, and the newly-diagnosed patient’s concept of his/her own self-image will suffer.
Figure 9-__
An illustration or photo of a patient with a distressed expression.
When Self-Image is at Risk
The impact of a low self-image, stated simply, is that patients who don’t feel good about themselves also don’t care what happens because they don’t feel that there is any reason to go on. They feel that they are not ‘fixable,’ or that, if they do experience improvement, they will nevertheless be left with losses – appearance, relationships, valued activities – that will result in an unacceptable lack of quality of life. In other words, they feel that their medical condition has so damaged their self-image that they don’t recognize themselves, and that others won’t, either.
Low self-image issues is not always apparent. Self-image is, instead, a state of mind that may reveal itself emotionally but, more likely, in statements that patients make regarding their perceptions of the own prognosis, their attitude toward the potential outcome of their treatment , or willingness to consider lifestyle adjustments and ongoing compliance. It is often through seemingly offhand comments that patients reveal the current state of their self-image. These comments often relate to the perception that ‘life won’t be the same again for me,’ ‘people will think there is something wrong with me,’ or ‘I’ll never be normal,’ for example. These are subtle hints that provide insights into a patient’s frame of mind.
Being Alert for Educational Moments
Healthcare professionals can help newly-diagnosed patients to recognize the impact that their diagnosis is having on their self-image, by being sensitive to the signs that patients are experience low self-image and intervening at that moment. These are ‘educational moments,’ a concept that was discussed in Chapter 3. By way of review, a educational moment is essentially an opportunity for a healthcare professional to intervene when a patient indicates, through words or body language, that they are experiencing destructive thoughts or emotions. So when a patient demonstrates that his/her self-image is being negatively affected by the diagnosis, the healthcare professional, by recognizing signs of low self-image, can use this a educational moment to help the patient understand that there is an alternative way to think or feel.
Examples of potential educational moments related to self-image are described below:
Body Image
Tony’s Story
Tony’s hip surgery left him with a number of side effects. While they were all inconvenient to various degrees, the one that bothered him the most was the loss of what he referred to as his ‘Mr. Atlas physique.’ Though he admitted that he was exaggerating when he referred to himself this way, he also told his physical therapy assistant, Jenn, that, a couple of years ago, when he was 49, he had the highest batting average on his company’s softball league. Tony had also been proud of his adherence to his routine at the gym, and told Jenn that he “was still keeping up with the young guys” and had intended to maintain this routine.
However, when Tony’s hip pain became increasingly difficult to ignore, he had finally had to take his doctor’s advice and undergo surgery. That was six months ago. Since then, he has been trying to regain his mobility, and the progress has been, for someone as active as Tony, frustratingly slow. During this time, he has felt his arm and legs muscles become weaker, and has gained a few pounds.
Tony said to Jenn: “I look in the mirror and I don’t see the Tony I used to see, the Tony who was at the top of his game. Instead, I see this middle-aged guy who needs to get to the gym! I like the way I used to look. And I don’t think people treat me with the same respect anymore. I know there is more to me than the way I look and how much muscle I have, but my body was an important part of who I was, and I worked hard to maintain it. Now what I am I?”
What Tony is experiencing:
Tony is an individual who has learned to place a high value on his appearance, and has worked hard to maintain it. He associates his looks with being respected, as well as envied, by others. Most likely, Tony also assumes that his appearance is valued more than other personal attributes. Therefore, changes in his appearance have a negative impact on his self-image. While he might be a somewhat extreme example, in Western culture it is common to place a high value on appearance – attractive face, fit body, and youthfulness. Even minor changes, such as weight gain, can be devastating if they are perceived as causing the patient to be ‘less than’ in the eyes of others.
What not to say to Tony
While newly-diagnosed patients experiencing low self-image resulting from perceptions of their body may react negatively to comments that they should simply accept the way they look, they will also react negatively to comments that are clearly overly-optimistic. Examples include:
“You won’t ever look the same again. That happens with your condition.”
“Remember that you’re still alive. Isn’t that worth not looking the same anymore?”
“You look great to me. I don’t know what you’re talking about.”
“You’ll be back to normal in no time. I’m sure this won’t last.”
What to say to Tony
When patients talk about losses like changes in appearance, they are not necessarily expecting their healthcare professional to ‘make things better.” Instead this is an opportunity to help by acknowledging feelings about changes in appearance. Simply being heard may be the patient needs at that moment, especially if his/her family is not able to have this discussion. ‘Normalizing’ this experience by explaining that other patients in the same situation also have concerns about their appearance, can also help the patient to realize that he/she is not alone in this experience. It can also be useful to encourage the patient to talk to the physician about concerns they have regarding appearance. Examples include:
“I know you’re really upset about the way that you look right now.”
“People recovering from the kind of surgery often experience changes in the way they look. This can be disappointing.”
“It’s always hard to adjust to a change.”
Keep in Mind: If someone asked you, “What do other people think about you?” your answer would most likely be a good summary of your self-image. Think about how you answer might be different on a day that you are feeling especially good about yourself versus a day when you have experienced a disappointment.
Feeling Helpless
Denise’s Story
Since she began her medication regimen, Denise has been asking for more and more help from her family and the healthcare professionals at the clinic where she receives her treatment. She tells them that she if having trouble adjusting to ‘all this medication in my system’ and that she is having trouble taking care of herself, and requests additional help around the house with chores that, in her family’s eyes, she should be able to do on her own. Denise has been reluctant to learn many of the self-care techniques that the nursing team has attempted to teach her, complaining that they are too hard and that she might hurt herself if she makes a mistake.
Last week, when one of the nurses, Monica, was teaching her how to give herself an injection, Denise held the syringe in her hand, then laid it on the table and burst into tears.
“I don’t think I can do this,” Denise said. “I am going to need to have someone else do this for me. I don’t think I can take care of myself anymore. There is too much to do, with these shots and everything, and I’m afraid I’ll make a mistake and make myself even sicker. I wish you had known me a couple of years ago. I didn’t need anybody to do anything for me back then. Now I feel like I’m so incompetent that can’t do anything for myself. I’m about two steps from being a total invalid.”
What Denise is experiencing:
Newly-diagnosed patients who are experiencing a low self-image as a result of a new and unfamiliar medical regimen may be concerned that their overall level of competence, beginning with the ability to take care of themselves, is in decline. While changes may be occurring that require additional assistance, they may be reacting in part to a fear about further decline in the future.
What not to say to Denise
Newly-diagnosed patients whose self-image is one of helplessness may resist comments from healthcare professionals that make them feel as if they are over-exaggerating their lack of ability to meet all of the challenges they are suddenly being faced with. However, it is also risky to encourage helplessness by implying that the demands may indeed be too much, because this may further reinforce a lower self-image. Examples include:
“You are only giving yourself an injection. It’s no big deal. We give hundreds of them here every day.”
‘You really need to help us more. There is no reason why you can’t be taking care of yourself.”
“This is probably all a lot more than you can handle.”
“You’re not the strong person you used to be, so now you may need a lot more help than before.”
What to say to Denise
Newly-diagnosed patients who are feeling that their competence – their ability to be an effective adult and to take care of themselves appropriate – is being jeopardized by their diagnosis, realistically or unrealistically, can benefit from some encouragement. Their self-image can be bolstered when the healthcare provider listens for self-defeating words and body language and responds with words that gently encourage them to focus on their strengths. It is always important to avoid adopting a patronizing tone when doing this, being careful to make sure that patients don’t feel as if they have done something wrong and are somehow being scolded , or that the healthcare professional is implying that life is ‘a bed of roses’ when clearly it is not.
It can be helpful to be aware of the abilities that patients value the most, and/or those that contribute toward feeling like life is ‘normal’ and reviewing these abilities with them. Reminding patients of strong support networks, including both friends/family as well as the healthcare team, can also be helpful. Simply acknowledging how patients are feeling can also be helpful in terms of making the patient to feel understood as well as providing an opportunity for them to discuss fears that loved ones may not be able to listen to.
Examples include:
“I know it’s hard to go through this. It feels like you are different in a lot of ways than you used to be.”
“I see that you really enjoy ___________ (activity that the healthcare professional has observed). Has that always been important to you?”
“I know you feel disappointed that you have had to cut back on your activities. This doesn’t mean that you can’t adjust your activity level and stay involved in life. What are things that you can keep on doing?”
“I have noticed that you have a lot of people around you who are on your side. You seem to have a lot of support.”
Figure 9-__
An illustration of a patient standing off to the side while others are socializing.
Changes in Personality
Sean’s Story
If Sean was asked to describe himself, he would probably refer to himself as ‘the life of the party.’ He was president of the Lion’s Club in his community, often assisted the minister at his church and, at his job, was known for his sense of humor, which he had a way of using in a way that put his co-workers at ease during times of stress. He and his wife, Marion, often hosted barbecues in their backyard, and their friends looked forward to the fun and great food. When Sean was received his diagnosis, his doctor told him that he would need to curtail some of his activities and that, at least initially, he might not have as much energy and enthusiasm while his body adjusted to the new medication.
Sean developed a relationship with Bennett, the phlebotomist at the lab he visits weekly, and he often talked about what was going on in his life as he adjusted to his condition and its treatment.
“Everybody looks to me to keep their spirits up,” Sean said. “They know I am going to walk into the room and get the energy going. They know I’m going to find the bright side to whatever’s going on, and I’m going to crack a few jokes to break the tension. I’m supposed to be the one that makes everybody happy. If I can’t be the Sean that everybody knows and loves, who am I?” He answered the question himself. “Nobody.”
What Sean is experiencing:
When newly-diagnosed patients fear that their personalities will be somehow changed by their condition, other related fears emerge. As Sean emphasized, they may fear that differences in the way they relate to others leaves them with ‘no personality,’ and, therefore, a major loss to their identity. Related to this is the fear that, if they are not themselves, they will lose recognition and respect from others, and will lose important relationships. They are most likely seeing evidence that the imaging they are projecting to others has indeed changed. Friends, for example, may comment that they don’t seem like themselves.
What not to say to Sean
Newly-diagnosed patients who are experiencing changes in the personality are likely to disbelieve suggestions that their personality has not changed, especially if others have commented that they seem to have changed.
Examples of what not to say include:
“You still seem like the same upbeat person to me. I am sure you are still a lot of fun.”
“Even if you aren’t feeling well, your friends know that you’ll be back to normal soon.”
“You told me you have also been a steady rock to your family. Do you think it might be time for someone else to do that job while you take a break?”
“Your family and friends will just find a new way to relate to you.”
What to say to Sean:
Healthcare professionals can be supportive of patients who experience, or fear that they will experience, changes in their personality by, first, being a supportive listener when patients express their concerns. They can also be helpful by relating to patients in a way that makes them feel that they are interesting and valued, engaging them in conversations, requesting their input, and acknowledging them for their contribution.
Examples include:
“I know it’s hard for you to feel like the take-charge person you have been in the past when you have this treatment ahead of you.”
“That was a very funny thing you said. You have a great sense of humor.”
“You have an interesting perspective on this. I see you have done some thinking about this.”
“It was great to talk to you today.”
SIDEBAR: Assessing When a Patient’s Self-Image is in Jeopardy
Newly-diagnosed patients often provide signs that their self-image has in some way been affected by their medical diagnosis. These signs include:
- Referring to what ‘life used to be like’ or ‘how things will never be the same’
- Describing examples of how others seem to be relating to them differently
- Avoidance of people they care about
- Avoidance of activities or responsibilities that they once excelled in
- Demonstrating a defeatist attitude, e.g. ‘I don’t even want to try this’ or ‘I know I won’t be able to do it anymore’
- Expressing fears about relationships through comments like ‘I’m not much good to her anymore’ or ‘I’m sure I won’t be any fun to have around’
Figure 9-__
A photo of a patient sitting in a slumped position.
SIDEBAR: BODY LANGUAGE
When a newly-diagnosed patient’s self-image is affected by their diagnosis, they may show it in their body language, including:
- Shrugging their shoulders in defeat
- Smiling, but in a sad way
- Shaking their head from side to side as if something had ended for them
- Looking away, as if no longer involved
- Avoiding eye contact, as if embarrassed or ashamed
- Looking downward
SIDEBAR: SELF-TALK
A lower self-image can be reinforced through self-talk that included:
I’m never going to be what I used to be.
People are going to look at me like I’m an invalid or a freak.
Why try when you will only be reminded of what a failure you have become.
Don’t push yourself or you will only get sicker.
What good am I if I can’t ___________ (work long hours, take care of everybody, head up the fundraiser, etc.) anymore.
Antidotes to negative self talk around self-image include:
I haven’t lost everything. I still have a lot to offer.
I’m doing the best I can. It doesn’t matter what people think when they look at me.
I can take a few steps at a time and regain some of my strength.
I’m dealing with a medical condition but I am not a victim or a loser.
I don’t have to ____________ to be a valuable person.
SIDEBAR: EDUCATIONAL MOMENT
When newly-diagnosed patients express concerns about their self-image, or demonstrate body language that indicates that they are feeling bad about themselves, this is an opportunity to be a listening ear. Most likely, they are too embarrassed or ashamed to talk about their self-image with friends or family. It can also be helpful to encourage patients to focus on strengths and not weaknesses.
Rx: Talking with a Newly Diagnosed Patient About Self-Image
Angel came into Dr. Rau’s office for his pre-surgery work-up – blood tests and an electrocardiogram test – and for Ava to review the directions for preparing for his surgery. Angel looked intently into Ava’s eyes, listening attentively while Ava went through the directions, but said little. After she finished, Angel acknowledged that he understood everything and didn’t have any questions. However, Ava had a feeling that Angel had not discussed his self-image concerns with anyone, and wanted to give him another opportunity to talk. She turned away from the computer that she had been using to update his chart, rested her hands on her lap in an open position, and leaned forward. She paused for a moment before speaking.
Ava: Angel, the last time you were here, you told me how you were feeling about how the surgery might affect you. You told me the surgery was going to cause you to really take a hit to your self-image.
Angel: Yes, I did tell you that. I may not look the same and, at least for awhile, I may not talk the same. This is all going to affect my relationships with other people, including my wife and friends, and it may affect my opportunities in my job as a teacher. My self-image is getting kicked pretty hard, I would say. Wouldn’t you say the same thing?
Ava: I would agree with you, Angel. As I said before, this is a lot for you to have to deal with at once. I can see that you are having a lot of feelings right now.
Angel: Yeah, this is a rough time.
Ava: The team here is standing by to listen, and to help you in any way we can.
Angel: I appreciate that. But do you have any advice for me?
Ava: I can talk to you about how other patients in similar situations have coped for one thing. Would you be interested in hearing about them?
Angel: I guess I would.
Ava: What I can tell you is that they felt the same way as you do. They were scared about how their lives would be if they looked or acted differently after surgery, how their friends and loved ones would treat them. They worried that their co-workers would have a different attitude toward them. They were afraid that they wouldn’t be as useful or as needed by others.
Angel: I can relate to that.
Ava: But most patients going through this have learned how to look at the positive side. They are glad to get back to their lives, even if their lives are going to be different. And they have learned to make accommodations, as have the other people around them.
Angel: But they aren’t the same anymore.
Ava: No, they aren’t, Angel. But they have adjusted by focusing on their strengths, and doing as much as possible to maintain the things that they value most in life. They tell themselves that they are doing the best they possibly can. Our self-image begins inside, right? And you are still the same person inside that you have always been. That hasn’t changed.
Angel: I guess that makes some sense.
Ava: A lot has happened in a short time – you got diagnosed, you are going to be treated for your condition, and you are going to experience some challenges. Give yourself some time to adjust to all of this, Angel. Be patient with yourself. Can you remind yourself that you are doing the best you can and that you are determined to do what you need to do to get through this?
Angel: I can try to do that.
Ava: Great. And I also recommend to patients that they have a strong support group in place, that they surround themselves with people who care about them. You seem to have quite a support group from what I’ve seen.
Angel: I definitely do. A whole fan club.
Ava: Good. Then that is a strength right there. You should feel good about being cared for that much. They are going to help you get through this.
Angel: Yes, I do.
Ava: But tell me something, Angel. Do the feelings get overwhelming at times?
Angel: I’m handling it okay now. I’m down but I’m not out.
Ava: Well, if you do feel overwhelmed, will you give one of us a call?
Angel: Yes I will.
Guidelines for Encouraging a Positive Self-Image
Based on the conversation with Angel and Ava, here are some guidelines for helping newly-diagnosed patients to deal with low self-image:
Show understanding.
When facing a crisis like a loss of self-image, newly-diagnosed patients need first and foremost to feel like they are being listened to. Friends and family often have difficulty having discussions that involve strong emotions, and to avoid their own helplessness, may insist that the patient ‘think positive’ or argue that there is nothing to worry about. Patients, in turn, may feel the need to protect their loved ones from having to discuss potential outcomes and be exposed to their raw emotions. Also, when patients may, out of both pride and a sense of responsibility, feel that they should not admit that their self-image is being affect by their medical condition. Notice that, in the conversation above, Ava began the conversation by reminding him that she, and the other members of the healthcare team, were available to listen.
Normalize the patient’s reaction.
While newly-diagnosed patients think that their experiences and their emotions are unique to them, they also appreciate knowing that others have gone through similar situations and have had similar reactions. Being reassured that their reactions are normal is a way of giving patients permission to express themselves fully. This reassurance also provides hope in that others are also coping with similar challenges. Furthermore, relating the experiences of other patients is a way for the healthcare professional to offer guidance without specifically telling patients what they should do. Instead, the healthcare professional is offering options that patients may, in turn, decide to ignore or to make use of. Ava let Angel know that she could tell what other patients in a similar situation had experienced, but it was his choice to hear this, or not. Newly-diagnosed patients do not always want to hear about other patients, at least when they are first facing a challenge, but may be more open to hearing this information at a later time.
Encourage realistic optimism.
Patients whose condition or its treatment is going to result in changes know that life is not going to be the same. They may not know exactly how it will be different, and may be exaggerating the potential for how much their lives will be different, or they may be in denial and therefore unrealistic, but they nonetheless know that change is coming. If they suspect that their healthcare professionals are somehow hiding the truth, or encouraging them to not face the truth, there is a risk that a lack of trust will result. Notice that Ava was honest with Angel. She agreed with him that his treatment was going to result in unwelcome changes. She also spoke about his potential for facing these changes and making adjustments, just as other patients in similar circumstances had been able to do.
Focus on strengths.
In spite of the numerous challenges that a patient may be facing, he/she possesses strengths that can be relied up to help them to meet these challenges. Knowing this can be a step toward bolstering a low self-image. Healthcare professionals may be aware of a newly-diagnosed patient’s strengths, including physical and emotional strengths, and therefore be able to remind him/her of some of them. Less specific strengths such as determination, a strong support network, and the willingness to be flexible in the face of change are strengths that can also be identified to help encourage a patient to look beyond limitations. The healthcare professional might also suggest brainstorming with the patient to identify their key strengths. Ava knew that, while Angel’s self-image was affected by his fears about how his surgery might impact his life, she identified his determined attitude as a strength, as well as an important aspect of his self-image.
Recommend support.
Newly-diagnosed patients who are feeling badly about themselves can benefit greatly from the support of friends and family, as well as from other patients facing similar challenges. Knowing that others care about them, and are facing their challenges with them, can result in improved self-image. Ava pointed out to Angel that he appeared to have a good support network, which she also identified as one of his strengths.
Evaluate the need for mental health services.
Newly-diagnosed patients who are suffering a reduced self-image may need the services of a mental health professional. For example, if they are feeling helpless/hopeless, they may be at risk for depression. If this is not addressed, their self-image will most likely suffer further, and they may become despondent to the point of non-compliance or other self-destructive behavior. Guidelines for evaluating a patient for depression are discussed in Chapter Three.
Summary
A medical diagnosis, with the challenges and losses that often accompany it, can impact self-image. Newly-diagnosed patients whose self-image has been affected by their diagnosis may feel so defeated that they do not participate actively in their treatment, and may be less compliant. Healthcare professionals can help patients experiencing a low self-image by listening and offering support and encouragement.